Women with Down syndrome who experienced early menopause were almost twice as likely to develop dementia at a younger age than those who entered menopause later, according to research in the January Journal of Alzheimer’s Disease. In a prospective longitudinal cohort study of dementia and mortality in women with Down syndrome, researchers followed 85 postmenopausal subjects for an average of 4.3 years and found a significant correlation between the age at menopause onset and age at diagnosis of dementia. Subjects with an earlier onset of menopause had a 1.8-fold increased risk of dementia. In addition, women who experienced menopause earlier had a twofold increased risk of dying younger.

White, elderly cancer survivors have a reduced risk of developing Alzheimer’s disease, as reported in the January 12 Neurology. Conversely, patients with Alzheimer’s disease have a reduced cancer risk, investigators found. In a prospective cohort study of 3,020 subjects ages 65 and older, the presence of Alzheimer’s disease was associated with a reduced risk of cancer hospitalizations, after adjustments for demographic and other factors. Prevalent cancer was also associated with a reduced risk of Alzheimer’s disease among white subjects after the researchers adjusted for demographics, number of apolipoprotein ε4 alleles, hypertension, diabetes, and coronary heart disease. The opposite was found in minorities, although the sample size was considered too small. No significant association was found between cancer and vascular dementia.

Ginkgo biloba did not preserve cognitive function any better than a placebo, per a study in the December 23, 2009, JAMA. In the randomized, double-blind, placebo-controlled Ginkgo Evaluation of Memory study, researchers at six academic medical centers in the US tracked 3,069 community-dwelling subjects ages 72 to 96 years for an average of 6.1 years. Subjects were given either a twice-daily dose of 120 mg extract of Ginkgo biloba or a placebo. Cognition was measured as rates of change over time in the Modified Mini-Mental State Examination, the cognitive subscale of the Alzheimer Disease Assessment Scale (ADAS-Cog), and neuropsychologic domains of memory, attention, visual-spatial construction, language, and executive functions. Investigators found no significant difference in cognitive decline between the herb and placebo.

A decreased ability to smell is common in patients with Alzheimer’s disease and may be a useful early diagnostic tool, researchers reported in the January 13 Journal of Neuroscience. The study linked olfactory dysfunction with an accumulation of amyloid-β protein in Alzheimer’s disease model mice. “The usefulness of olfactory screens to serve as informative indicators of Alzheimer’s is precluded by a lack of knowledge regarding why the disease impacts olfaction,” the study authors stated. The investigators assayed olfactory perception and amyloid-β deposition in the genetically engineered mice and found that amyloid-β pathology first occurred in an area of the brain responsible for smelling. Mice with higher concentrations of amyloid-β also displayed olfactory dysfunction. Researchers noted the “odor cross-habitation test [was] a powerful behavioral assay…[which] may serve to monitor the efficacy of therapies aimed at reducing amyloid-β.”

The Lancet has retracted the 1998 paper by Wakefield et al that suggested a link between autism and the childhood measles, mumps, and rubella (MMR) vaccine. The retraction, published in the February 2 online issue, follows a judgment by the UK General Medical Council’s Fitness to Practice Panel on January 28. “It has become clear that several elements of the 1998 paper by Wakefield et al are incorrect,” the editors wrote. “In particular, the claims in the original paper that children were ‘consecutively referred’ and that investigations were ‘approved’ by the local ethics committee have been proven to be false.” In 2004, 10 of the original authors retracted parts of the study, stating, “in this paper no causal link was established between MMR vaccine and autism as the data were insufficient.”

Advanced maternal age may be linked to an increased risk of autism, researchers reported in the February 8 online Autism Research. In a study of 12,159 cases of autism from a pool of almost 5 million births between 1990 and 1999, the investigators found a monotonic increased risk of autism related to advancing maternal age (40 and older) regardless of paternal age. However, the study authors noted fathers aged 40 and up who mated with women younger than 30 also had an increased risk of autistic offspring, compared with men in their mid- to late-20s. Yet when the mother was older than 30 and the father was 40 or older, the associated autism risk was similar to that of younger men. The investigators also noted that the “recent trend towards delaying childbearing contributed approximately a 4.6% increase in autism diagnoses in California over the decade.”

Depression and migraine headaches appear to share a common genetic factor, a Dutch study of 2,652 people found. As reported in the January 26 Neurology, researchers compared heritability estimates among members of the Erasmus Rucphen family for migraine with and without depression, and depression rates between migraineurs and controls. Of the total study population, 360 had migraines, 151 of whom experienced migraine aura as well. One-quarter of migraineurs also had depression, compared with 13% of the controls. Odds ratios for depression in patients with migraine were 1.29 for those without aura and 1.70 for those with aura. “There is a bidirectional association between depression and migraine, in particular migraine with aura, which can be explained, at least partly, by shared genetic factors,” the study authors noted.

The FDA has approved Ampyra (dalfampridine) extended-release tablets to improve walking in patients with multiple sclerosis (MS). In clinical trials, patients treated with dalfampridine had faster walking speeds than those treated with a placebo. It is the first report in which a drug for MS improved function that was lost as a result of the disease. The most common side effects reported were urinary tract infection, insomnia, dizziness, headache, nausea, and others. When taken in doses greater than 10 mg twice a day, seizures may occur. It should not be used in patients with moderate to severe kidney disease. Dalfampridine is distributed by Acorda Therapeutics Inc of Hawthorne, New York.

Black patients with multiple sclerosis showed increased tissue damage and higher lesion volumes compared with white patients, according to research in the February 16 Neurology. In a study of 567 patients, 488 of whom were white and 79 were black, investigators compared quantitative MRI evaluations including T1-, T2-, and gadolinium contrast-enhancing lesion volumes and contrast-enhancing number, global and tissue-specific brain atrophy, and magnetization transfer ratios (MTR) in lesions and normal-appearing gray matter (NAGM) and white matter (NAWM). The researchers found that MTR values in lesions and in NAGM and NAWM were significantly lower in black subjects than in whites, and T1- and T2- lesion volumes were greater, both of which indicate a more aggressive clinical disease.

Dopamine agonists can cause or exacerbate compulsive behaviors in patients with Parkinson’s, according to research published in the January 14 Neuron. “A constellation of pathological behaviors, including gambling, shopping, binge eating, and hypersexuality is seen in 17% of patients on dopamine agonists,” the study authors wrote. Because reinforcement learning algorithms allow for computation of prediction error, the researchers used a reinforcement learning model to deconstruct decision-making processes dysregulated by dopamine agonists in patients who are susceptible to compulsive behaviors. The investigators found that the medications increased the rate of learning from gain outcomes and increased striatal prediction error activity, signifying a “better than expected” outcome.

Patients with acute ischemic stroke admitted to the hospital on the weekend are more likely to receive t-PA than those admitted on a weekday, a study in the January Archives of Neurology reported. Researchers analyzed rates of t-PA administration, as well as death rates, among 78,657stroke patients admitted to Virginia hospitals between 1998 and 2006 and found weekend patients (n=20,279) were 20% more likely to receive t-PA than weekday patients (n=58,378). There was no statistically significant difference in patient mortality based on day of admission; however, because a greater percentage of weekend patients received t-PA while death rates remained equal, the study authors noted that those treated with t-PA may be more likely to die in the hospital.

Impaired cognitive function in elderly men may be an independent predictor of subsequent stroke, according to a report in the February 2 Neurology. In a study of 930 elderly men (mean age, 70), Swedish researchers found that taking longer to complete the Trail Making Test B increased stroke risk by as much as 300% for those in the highest quartile, compared with those in the lowest quartile. Each time increase of 1 SD was associated with a 1.48 higher risk of stroke. “Our results extend previous findings of cognitive decline as an independent predictor of stroke and indicate that the risk of brain infarction is increased already in the subclinical phase of cognitive deficit,” the study authors wrote.

Women with Down syndrome who experienced early menopause were almost twice as likely to develop dementia at a younger age than those who entered menopause later, according to research in the January Journal of Alzheimer’s Disease. In a prospective longitudinal cohort study of dementia and mortality in women with Down syndrome, researchers followed 85 postmenopausal subjects for an average of 4.3 years and found a significant correlation between the age at menopause onset and age at diagnosis of dementia. Subjects with an earlier onset of menopause had a 1.8-fold increased risk of dementia. In addition, women who experienced menopause earlier had a twofold increased risk of dying younger.

White, elderly cancer survivors have a reduced risk of developing Alzheimer’s disease, as reported in the January 12 Neurology. Conversely, patients with Alzheimer’s disease have a reduced cancer risk, investigators found. In a prospective cohort study of 3,020 subjects ages 65 and older, the presence of Alzheimer’s disease was associated with a reduced risk of cancer hospitalizations, after adjustments for demographic and other factors. Prevalent cancer was also associated with a reduced risk of Alzheimer’s disease among white subjects after the researchers adjusted for demographics, number of apolipoprotein ε4 alleles, hypertension, diabetes, and coronary heart disease. The opposite was found in minorities, although the sample size was considered too small. No significant association was found between cancer and vascular dementia.

Ginkgo biloba did not preserve cognitive function any better than a placebo, per a study in the December 23, 2009, JAMA. In the randomized, double-blind, placebo-controlled Ginkgo Evaluation of Memory study, researchers at six academic medical centers in the US tracked 3,069 community-dwelling subjects ages 72 to 96 years for an average of 6.1 years. Subjects were given either a twice-daily dose of 120 mg extract of Ginkgo biloba or a placebo. Cognition was measured as rates of change over time in the Modified Mini-Mental State Examination, the cognitive subscale of the Alzheimer Disease Assessment Scale (ADAS-Cog), and neuropsychologic domains of memory, attention, visual-spatial construction, language, and executive functions. Investigators found no significant difference in cognitive decline between the herb and placebo.

A decreased ability to smell is common in patients with Alzheimer’s disease and may be a useful early diagnostic tool, researchers reported in the January 13 Journal of Neuroscience. The study linked olfactory dysfunction with an accumulation of amyloid-β protein in Alzheimer’s disease model mice. “The usefulness of olfactory screens to serve as informative indicators of Alzheimer’s is precluded by a lack of knowledge regarding why the disease impacts olfaction,” the study authors stated. The investigators assayed olfactory perception and amyloid-β deposition in the genetically engineered mice and found that amyloid-β pathology first occurred in an area of the brain responsible for smelling. Mice with higher concentrations of amyloid-β also displayed olfactory dysfunction. Researchers noted the “odor cross-habitation test [was] a powerful behavioral assay…[which] may serve to monitor the efficacy of therapies aimed at reducing amyloid-β.”

The Lancet has retracted the 1998 paper by Wakefield et al that suggested a link between autism and the childhood measles, mumps, and rubella (MMR) vaccine. The retraction, published in the February 2 online issue, follows a judgment by the UK General Medical Council’s Fitness to Practice Panel on January 28. “It has become clear that several elements of the 1998 paper by Wakefield et al are incorrect,” the editors wrote. “In particular, the claims in the original paper that children were ‘consecutively referred’ and that investigations were ‘approved’ by the local ethics committee have been proven to be false.” In 2004, 10 of the original authors retracted parts of the study, stating, “in this paper no causal link was established between MMR vaccine and autism as the data were insufficient.”

Advanced maternal age may be linked to an increased risk of autism, researchers reported in the February 8 online Autism Research. In a study of 12,159 cases of autism from a pool of almost 5 million births between 1990 and 1999, the investigators found a monotonic increased risk of autism related to advancing maternal age (40 and older) regardless of paternal age. However, the study authors noted fathers aged 40 and up who mated with women younger than 30 also had an increased risk of autistic offspring, compared with men in their mid- to late-20s. Yet when the mother was older than 30 and the father was 40 or older, the associated autism risk was similar to that of younger men. The investigators also noted that the “recent trend towards delaying childbearing contributed approximately a 4.6% increase in autism diagnoses in California over the decade.”

Depression and migraine headaches appear to share a common genetic factor, a Dutch study of 2,652 people found. As reported in the January 26 Neurology, researchers compared heritability estimates among members of the Erasmus Rucphen family for migraine with and without depression, and depression rates between migraineurs and controls. Of the total study population, 360 had migraines, 151 of whom experienced migraine aura as well. One-quarter of migraineurs also had depression, compared with 13% of the controls. Odds ratios for depression in patients with migraine were 1.29 for those without aura and 1.70 for those with aura. “There is a bidirectional association between depression and migraine, in particular migraine with aura, which can be explained, at least partly, by shared genetic factors,” the study authors noted.

The FDA has approved Ampyra (dalfampridine) extended-release tablets to improve walking in patients with multiple sclerosis (MS). In clinical trials, patients treated with dalfampridine had faster walking speeds than those treated with a placebo. It is the first report in which a drug for MS improved function that was lost as a result of the disease. The most common side effects reported were urinary tract infection, insomnia, dizziness, headache, nausea, and others. When taken in doses greater than 10 mg twice a day, seizures may occur. It should not be used in patients with moderate to severe kidney disease. Dalfampridine is distributed by Acorda Therapeutics Inc of Hawthorne, New York.

Black patients with multiple sclerosis showed increased tissue damage and higher lesion volumes compared with white patients, according to research in the February 16 Neurology. In a study of 567 patients, 488 of whom were white and 79 were black, investigators compared quantitative MRI evaluations including T1-, T2-, and gadolinium contrast-enhancing lesion volumes and contrast-enhancing number, global and tissue-specific brain atrophy, and magnetization transfer ratios (MTR) in lesions and normal-appearing gray matter (NAGM) and white matter (NAWM). The researchers found that MTR values in lesions and in NAGM and NAWM were significantly lower in black subjects than in whites, and T1- and T2- lesion volumes were greater, both of which indicate a more aggressive clinical disease.

Dopamine agonists can cause or exacerbate compulsive behaviors in patients with Parkinson’s, according to research published in the January 14 Neuron. “A constellation of pathological behaviors, including gambling, shopping, binge eating, and hypersexuality is seen in 17% of patients on dopamine agonists,” the study authors wrote. Because reinforcement learning algorithms allow for computation of prediction error, the researchers used a reinforcement learning model to deconstruct decision-making processes dysregulated by dopamine agonists in patients who are susceptible to compulsive behaviors. The investigators found that the medications increased the rate of learning from gain outcomes and increased striatal prediction error activity, signifying a “better than expected” outcome.

Patients with acute ischemic stroke admitted to the hospital on the weekend are more likely to receive t-PA than those admitted on a weekday, a study in the January Archives of Neurology reported. Researchers analyzed rates of t-PA administration, as well as death rates, among 78,657stroke patients admitted to Virginia hospitals between 1998 and 2006 and found weekend patients (n=20,279) were 20% more likely to receive t-PA than weekday patients (n=58,378). There was no statistically significant difference in patient mortality based on day of admission; however, because a greater percentage of weekend patients received t-PA while death rates remained equal, the study authors noted that those treated with t-PA may be more likely to die in the hospital.

Impaired cognitive function in elderly men may be an independent predictor of subsequent stroke, according to a report in the February 2 Neurology. In a study of 930 elderly men (mean age, 70), Swedish researchers found that taking longer to complete the Trail Making Test B increased stroke risk by as much as 300% for those in the highest quartile, compared with those in the lowest quartile. Each time increase of 1 SD was associated with a 1.48 higher risk of stroke. “Our results extend previous findings of cognitive decline as an independent predictor of stroke and indicate that the risk of brain infarction is increased already in the subclinical phase of cognitive deficit,” the study authors wrote.

Women with Down syndrome who experienced early menopause were almost twice as likely to develop dementia at a younger age than those who entered menopause later, according to research in the January Journal of Alzheimer’s Disease. In a prospective longitudinal cohort study of dementia and mortality in women with Down syndrome, researchers followed 85 postmenopausal subjects for an average of 4.3 years and found a significant correlation between the age at menopause onset and age at diagnosis of dementia. Subjects with an earlier onset of menopause had a 1.8-fold increased risk of dementia. In addition, women who experienced menopause earlier had a twofold increased risk of dying younger.

White, elderly cancer survivors have a reduced risk of developing Alzheimer’s disease, as reported in the January 12 Neurology. Conversely, patients with Alzheimer’s disease have a reduced cancer risk, investigators found. In a prospective cohort study of 3,020 subjects ages 65 and older, the presence of Alzheimer’s disease was associated with a reduced risk of cancer hospitalizations, after adjustments for demographic and other factors. Prevalent cancer was also associated with a reduced risk of Alzheimer’s disease among white subjects after the researchers adjusted for demographics, number of apolipoprotein ε4 alleles, hypertension, diabetes, and coronary heart disease. The opposite was found in minorities, although the sample size was considered too small. No significant association was found between cancer and vascular dementia.

Ginkgo biloba did not preserve cognitive function any better than a placebo, per a study in the December 23, 2009, JAMA. In the randomized, double-blind, placebo-controlled Ginkgo Evaluation of Memory study, researchers at six academic medical centers in the US tracked 3,069 community-dwelling subjects ages 72 to 96 years for an average of 6.1 years. Subjects were given either a twice-daily dose of 120 mg extract of Ginkgo biloba or a placebo. Cognition was measured as rates of change over time in the Modified Mini-Mental State Examination, the cognitive subscale of the Alzheimer Disease Assessment Scale (ADAS-Cog), and neuropsychologic domains of memory, attention, visual-spatial construction, language, and executive functions. Investigators found no significant difference in cognitive decline between the herb and placebo.

A decreased ability to smell is common in patients with Alzheimer’s disease and may be a useful early diagnostic tool, researchers reported in the January 13 Journal of Neuroscience. The study linked olfactory dysfunction with an accumulation of amyloid-β protein in Alzheimer’s disease model mice. “The usefulness of olfactory screens to serve as informative indicators of Alzheimer’s is precluded by a lack of knowledge regarding why the disease impacts olfaction,” the study authors stated. The investigators assayed olfactory perception and amyloid-β deposition in the genetically engineered mice and found that amyloid-β pathology first occurred in an area of the brain responsible for smelling. Mice with higher concentrations of amyloid-β also displayed olfactory dysfunction. Researchers noted the “odor cross-habitation test [was] a powerful behavioral assay…[which] may serve to monitor the efficacy of therapies aimed at reducing amyloid-β.”

The Lancet has retracted the 1998 paper by Wakefield et al that suggested a link between autism and the childhood measles, mumps, and rubella (MMR) vaccine. The retraction, published in the February 2 online issue, follows a judgment by the UK General Medical Council’s Fitness to Practice Panel on January 28. “It has become clear that several elements of the 1998 paper by Wakefield et al are incorrect,” the editors wrote. “In particular, the claims in the original paper that children were ‘consecutively referred’ and that investigations were ‘approved’ by the local ethics committee have been proven to be false.” In 2004, 10 of the original authors retracted parts of the study, stating, “in this paper no causal link was established between MMR vaccine and autism as the data were insufficient.”

Advanced maternal age may be linked to an increased risk of autism, researchers reported in the February 8 online Autism Research. In a study of 12,159 cases of autism from a pool of almost 5 million births between 1990 and 1999, the investigators found a monotonic increased risk of autism related to advancing maternal age (40 and older) regardless of paternal age. However, the study authors noted fathers aged 40 and up who mated with women younger than 30 also had an increased risk of autistic offspring, compared with men in their mid- to late-20s. Yet when the mother was older than 30 and the father was 40 or older, the associated autism risk was similar to that of younger men. The investigators also noted that the “recent trend towards delaying childbearing contributed approximately a 4.6% increase in autism diagnoses in California over the decade.”

Depression and migraine headaches appear to share a common genetic factor, a Dutch study of 2,652 people found. As reported in the January 26 Neurology, researchers compared heritability estimates among members of the Erasmus Rucphen family for migraine with and without depression, and depression rates between migraineurs and controls. Of the total study population, 360 had migraines, 151 of whom experienced migraine aura as well. One-quarter of migraineurs also had depression, compared with 13% of the controls. Odds ratios for depression in patients with migraine were 1.29 for those without aura and 1.70 for those with aura. “There is a bidirectional association between depression and migraine, in particular migraine with aura, which can be explained, at least partly, by shared genetic factors,” the study authors noted.

The FDA has approved Ampyra (dalfampridine) extended-release tablets to improve walking in patients with multiple sclerosis (MS). In clinical trials, patients treated with dalfampridine had faster walking speeds than those treated with a placebo. It is the first report in which a drug for MS improved function that was lost as a result of the disease. The most common side effects reported were urinary tract infection, insomnia, dizziness, headache, nausea, and others. When taken in doses greater than 10 mg twice a day, seizures may occur. It should not be used in patients with moderate to severe kidney disease. Dalfampridine is distributed by Acorda Therapeutics Inc of Hawthorne, New York.

Black patients with multiple sclerosis showed increased tissue damage and higher lesion volumes compared with white patients, according to research in the February 16 Neurology. In a study of 567 patients, 488 of whom were white and 79 were black, investigators compared quantitative MRI evaluations including T1-, T2-, and gadolinium contrast-enhancing lesion volumes and contrast-enhancing number, global and tissue-specific brain atrophy, and magnetization transfer ratios (MTR) in lesions and normal-appearing gray matter (NAGM) and white matter (NAWM). The researchers found that MTR values in lesions and in NAGM and NAWM were significantly lower in black subjects than in whites, and T1- and T2- lesion volumes were greater, both of which indicate a more aggressive clinical disease.

Dopamine agonists can cause or exacerbate compulsive behaviors in patients with Parkinson’s, according to research published in the January 14 Neuron. “A constellation of pathological behaviors, including gambling, shopping, binge eating, and hypersexuality is seen in 17% of patients on dopamine agonists,” the study authors wrote. Because reinforcement learning algorithms allow for computation of prediction error, the researchers used a reinforcement learning model to deconstruct decision-making processes dysregulated by dopamine agonists in patients who are susceptible to compulsive behaviors. The investigators found that the medications increased the rate of learning from gain outcomes and increased striatal prediction error activity, signifying a “better than expected” outcome.

Patients with acute ischemic stroke admitted to the hospital on the weekend are more likely to receive t-PA than those admitted on a weekday, a study in the January Archives of Neurology reported. Researchers analyzed rates of t-PA administration, as well as death rates, among 78,657stroke patients admitted to Virginia hospitals between 1998 and 2006 and found weekend patients (n=20,279) were 20% more likely to receive t-PA than weekday patients (n=58,378). There was no statistically significant difference in patient mortality based on day of admission; however, because a greater percentage of weekend patients received t-PA while death rates remained equal, the study authors noted that those treated with t-PA may be more likely to die in the hospital.

Impaired cognitive function in elderly men may be an independent predictor of subsequent stroke, according to a report in the February 2 Neurology. In a study of 930 elderly men (mean age, 70), Swedish researchers found that taking longer to complete the Trail Making Test B increased stroke risk by as much as 300% for those in the highest quartile, compared with those in the lowest quartile. Each time increase of 1 SD was associated with a 1.48 higher risk of stroke. “Our results extend previous findings of cognitive decline as an independent predictor of stroke and indicate that the risk of brain infarction is increased already in the subclinical phase of cognitive deficit,” the study authors wrote.

A 6-year-old girl was brought by her parents to the emergency department (ED) with an elevated heart rate. According to the parents, the girl was carrying her younger sister when they both fell, landing on their buttocks. The child told them that her heart was beating fast, and the parents said she appeared to be on the verge of fainting.

They stated that their daughter was healthy and active; they denied previous episodes of shortness of breath, headache, weakness, tachycardia, syncope, or fatigue with exercise. Her caffeine intake, they claimed, was limited to one small cup of soda they allowed her each week.

Initial evaluation in the ED revealed an anxious child with tachycardia and shortness of breath. She presented with a temperature of 98.3°F (36.8°C); pulse, 210 beats/min; respirations, 33 breaths/min; blood pressure, 100/72 mm Hg; weight, 78 lb; height, 45 in; and BMI, 27.1. ECG revealed a heart rate exceeding 210 beats/min, and a pediatric cardiologist made a diagnosis of supraventricular tachycardia (SVT).

The pediatric cardiologist prescribed an adenosine IV drip, which successfully stabilized the child’s heart to sinus rhythm. After three hours in the ED, the patient was discharged with a stable heart rate of 100 beats/min. (It is well known that heart rate regulation changes significantly during development; this is most obvious in higher basal rates in infants and children, compared with adults.¹)

The parents were advised to administer atenolol 12.5 mg (one tablet) twice daily and to make a follow-up appointment with a pediatric electrophysiologist. (Although atenolol is not currently FDA approved for this use, a multicenter prospective randomized controlled trial comparing digoxin with beta-blockers for the treatment of SVT in children is presently under way.²)

At that appointment, the pediatric electrophysiologist provided information to the parents regarding the therapeutic options for SVT. The parents continued to administer atenolol to the child, as was deemed necessary until any accessory electrical pathway could be identified and, if so, an ablation procedure could be performed. They were uncertain how to proceed so long as their daughter experienced no recurrent episodes of SVT while receiving pharmacologic therapy.

However, six months after the initial episode, the child (then age 7) presented to the ED once again with recurrent SVT. The pediatric cardiologist ordered an adenosine IV drip, which resulted in successful conversion to sinus rhythm. The parents were instructed to increase the child’s atenolol dosage to 25 mg twice a day.

Six months later, after extensive research and consultation, the parents agreed to an ablation procedure in order to prevent further episodes of SVT. Upon their informed consent, the child was sent to a cardiac catheterization laboratory for an electrophysiology study (EPS), which confirmed the presence of an accessory pathway, as well as the diagnosis of atrioventricular reciprocating tachycardia (AVRT). The procedure was followed by radiofrequency catheter ablation to correct the 7-year-old patient’s accessory pathway–mediated reentry tachycardia.

Discussion
SVT, also known as paroxysmal supraventricular tachycardia (PSVT), is one of the most common symptomatic pediatric arrhythmias, affecting between one in 25,000 and one in 250 children.³ It is defined as rapid heart rhythm (140 to 240 beats/min) that is caused by the presence of additional electrical connections and/or congenital muscle fibers between the atrium and the ventricle or within the atrioventricular (AV) node that did not, for unknown reasons, separate completely during development.⁴ SVT can be triggered by physical or psychological stress automaticity.³

Approximately 50% of children with SVT present with a first episode before age 1. SVT usually occurs in early childhood, between ages 6 and 9.⁴ Almost 90% of pediatric patients with SVT are diagnosed with a reentry mechanism.³ The symptoms experienced may be resolved pharmacologically or by means of an invasive therapy. Serious sequelae associated with SVT include heart failure and cardiac arrest.

For children with rare and mildly symptomatic episodes in whom SVT is easily terminated, the SVT may not warrant treatment. However, it may be advisable to offer medical therapy or transcatheter ablation as therapeutic options for children with episodes that are difficult to terminate, occur frequently, or occur during participation in athletics.⁴

Pathophysiology
SVT generally presents as one of three types: AVRT, which is also known as Wolff-Parkinson-White syndrome; atrioventricular nodal reentry tachycardia (AVNRT); and automatic tachycardia (AT).

AVRT, the most common type of SVT, comprises about 90% of pediatric cases. It is defined by the presence of one or more accessory conduction pathways that are anatomically separated from the normal cardiac conduction system.5 AVRT may be orthodromic (that is, the arrhythmia circuit proceeds down the AV node and retrograde up the accessory conduction pathway) or antedromic (ie, proceeding down the accessory pathway and up the AV node⁵; see figure.^6,7)

AVNRT, considered the second most common type of SVT in children, accounts for about 10% of pediatric cases. AVNRT is caused by an interaction between the two types of pathways within the AV node—one with a fast conduction time and a short refractory period, and the other with a slow conduction time and a long refractory period. AVNRT occurs when the antegrade conduction block in the fast pathway results in conduction over the slow pathway and back up the fast pathway, forming a microreentrant circuit.⁵

AT is the result of rapid depolarization from an automatic focus originating within the atria but outside the sinus node.³

Patient Presentation and History
The typical presentation of AVRT in children of school age includes palpitations, chest pain or tightness, dizziness, anxiety, decrease in exercise tolerance, easy fatigability, and/or shortness of breath.³ Onset is described as abrupt, while termination of SVT is described as slower because the catecholamine levels are typically elevated.⁴

The frequency and duration of SVT can vary greatly, from a few minutes to a few hours; it can occur as regularly as daily or as uncommonly as once or twice per year.⁴ Additionally, SVT symptoms can go unrecognized until a cardiac dysfunction develops. As for the patient in the case study, no apparent factor in her history was identified that may have induced SVT.

The differential diagnosis for SVT is broad, including sinus tachycardia, multifocal atrial tachycardia, and SVT with aberrancy.⁸ Additional considerations include stress, anxiety, hyperthyroidism, electrolyte abnormalities, and dehydration—any of which can present with a tachycardia response.⁴ Furthermore, clinicians are often unlikely to diagnose a child with any cardiac problem because chest pain is more commonly a presenting symptom of a pulmonary or musculoskeletal condition than a cardiac problem.³

Physical Examination
SVT can be diagnosed based on medical history and physical examination. During the physical examination, providers will assess the patient’s blood pressure and pulse, auscultate heart and lung sounds, assess the veins in the patient’s neck for different types of pulsations, and conduct cardiac maneuvers, including the Valsalva maneuver and carotid sinus massage.^9,10

Laboratory Work-up and Diagnosis
Three specific tests help clinicians monitor and evaluate a patient’s conduction system. ECG is important to assess the heart rhythm both at baseline and when symptoms are occurring, if possible.³ Ambulatory ECG (ie, Holter monitoring, event recorders) record the patient’s heart rhythm on a continuous basis.

An EPS, which is performed to classify the mechanism of SVT, is conducted by inserting one or more electrocatheters into the heart by way of the femoral vein or other peripheral vessel.³ Pacing and sensing electrodes at the ends of the catheters record local intracardiac electrical activity and timing information, providing a detailed analysis of the heart’s electrical activity. The EPS is critical to determine the presence of one or more extra electrical pathways within the heart and to localize it by region.^3,11 An ablation procedure may follow.

Management Options
SVT can be treated pharmacologically or nonpharmacologically. First-line pharmacologic options include certain beta-blockers (including atenolol and propranolol), digoxin, and calcium channel blockers. Second-line pharmacologic treatments include amiodarone, flecainide, and sotalol,⁴ all of which are contraindicated in children younger than 1 year because of these patients’ hemodynamic dependency on the heart and inability to generate stroke volume.³ Pharmacologic treatment of SVT is associated with a 68% success rate in children⁴ (see Table 1⁴).

For children in whom pharmacologic treatment is ineffective, an ablation procedure may be performed. Radiofrequency catheter ablation is currently considered first-line therapy for AVRT and AVNRT.¹² In this invasive procedure, intracardiac electrical mapping is performed and the initiating focus of the arrhythmia or the accessory electrical pathway that has been identified within the heart is destroyed by radiofrequency energy, delivered by electrocatheter. Ablations performed during the acute phase of SVT have a 95% success rate.^3,13

Cryoablation is a relatively new treatment in which liquid nitrous oxide is used to cool the catheter to subfreezing temperatures, enabling it to destroy the myocardial tissue by freezing.^3,14 The advantage of cryoablation is the option of reversible cooling, which allows the electrophysiologist to test the area first, confirming the accuracy of the apparent location accessory pathway.¹⁵

Noninvasive, nonpharmacologic interventions that increase the refractoriness of the AV node may be successful in terminating the tachyarrhythmia during episodes of SVT (see Table 2^3,9,13,16). They are used to terminate and diagnose tachydysrhythmias, increase parasympathetic tone, and slow conduction through the AV node.³

Patient Education
It is very important for health care providers to relieve parents’ and caregivers’ stress, anxiety, and uncertainty by educating them about the child’s cardiac condition of SVT. Information to convey include an understanding of what SVT is, what may cause it, what triggers the patient should avoid, what treatments are available and appropriate (including the maneuvers shown in Table 2), and what outcomes may be expected. An excellent patient/family education handout from the Children’s Hospitals and Clinics of Minnesota¹⁷ is available at www.childrensmn.org/Manuals/PFS/Condill/018303.pdf.

Follow-Up
Primary care providers must emphasize the importance of monitoring the patient’s progress, based on the severity of his or her SVT symptoms. The provider may choose to monitor the patient for a few weeks or a few months, assessing the frequency of arrhythmia recurrence and the heart rate, to adjust or substitute medications based on repeat ECG or Holter evaluations, and to plan further therapy, should the condition worsen.⁵

The Case Patient
One month after undergoing radiofrequency catheter ablation, the child presented to the pediatric cardiologist for follow-up. Since the procedure, she had been without any symptoms referable to the cardiovascular system. She denied experiencing any fast heart rate, palpitations, chest pain, shortness of breath, or dizziness. ECG demonstrated normal sinus rhythm.

Two years after undergoing radiofrequency ablation, the child is functioning at a normal activity level with no recurrence of SVT episodes.

Conclusion
The purpose of this case study is to improve primary care providers’ understanding of SVT in children and to convey the importance of identifying the condition in a timely manner and referring patients to a pediatric cardiologist or electrophysiologist. For most children affected by SVT, a regimen of pharmacologic and/or nonpharmacologic treatment—supported by detailed education for their parents and caregivers—can allow them to live a healthy, normal life.

A 6-year-old girl was brought by her parents to the emergency department (ED) with an elevated heart rate. According to the parents, the girl was carrying her younger sister when they both fell, landing on their buttocks. The child told them that her heart was beating fast, and the parents said she appeared to be on the verge of fainting.

They stated that their daughter was healthy and active; they denied previous episodes of shortness of breath, headache, weakness, tachycardia, syncope, or fatigue with exercise. Her caffeine intake, they claimed, was limited to one small cup of soda they allowed her each week.

Initial evaluation in the ED revealed an anxious child with tachycardia and shortness of breath. She presented with a temperature of 98.3°F (36.8°C); pulse, 210 beats/min; respirations, 33 breaths/min; blood pressure, 100/72 mm Hg; weight, 78 lb; height, 45 in; and BMI, 27.1. ECG revealed a heart rate exceeding 210 beats/min, and a pediatric cardiologist made a diagnosis of supraventricular tachycardia (SVT).

The pediatric cardiologist prescribed an adenosine IV drip, which successfully stabilized the child’s heart to sinus rhythm. After three hours in the ED, the patient was discharged with a stable heart rate of 100 beats/min. (It is well known that heart rate regulation changes significantly during development; this is most obvious in higher basal rates in infants and children, compared with adults.¹)

The parents were advised to administer atenolol 12.5 mg (one tablet) twice daily and to make a follow-up appointment with a pediatric electrophysiologist. (Although atenolol is not currently FDA approved for this use, a multicenter prospective randomized controlled trial comparing digoxin with beta-blockers for the treatment of SVT in children is presently under way.²)

At that appointment, the pediatric electrophysiologist provided information to the parents regarding the therapeutic options for SVT. The parents continued to administer atenolol to the child, as was deemed necessary until any accessory electrical pathway could be identified and, if so, an ablation procedure could be performed. They were uncertain how to proceed so long as their daughter experienced no recurrent episodes of SVT while receiving pharmacologic therapy.

However, six months after the initial episode, the child (then age 7) presented to the ED once again with recurrent SVT. The pediatric cardiologist ordered an adenosine IV drip, which resulted in successful conversion to sinus rhythm. The parents were instructed to increase the child’s atenolol dosage to 25 mg twice a day.

Six months later, after extensive research and consultation, the parents agreed to an ablation procedure in order to prevent further episodes of SVT. Upon their informed consent, the child was sent to a cardiac catheterization laboratory for an electrophysiology study (EPS), which confirmed the presence of an accessory pathway, as well as the diagnosis of atrioventricular reciprocating tachycardia (AVRT). The procedure was followed by radiofrequency catheter ablation to correct the 7-year-old patient’s accessory pathway–mediated reentry tachycardia.

Discussion
SVT, also known as paroxysmal supraventricular tachycardia (PSVT), is one of the most common symptomatic pediatric arrhythmias, affecting between one in 25,000 and one in 250 children.³ It is defined as rapid heart rhythm (140 to 240 beats/min) that is caused by the presence of additional electrical connections and/or congenital muscle fibers between the atrium and the ventricle or within the atrioventricular (AV) node that did not, for unknown reasons, separate completely during development.⁴ SVT can be triggered by physical or psychological stress automaticity.³

Approximately 50% of children with SVT present with a first episode before age 1. SVT usually occurs in early childhood, between ages 6 and 9.⁴ Almost 90% of pediatric patients with SVT are diagnosed with a reentry mechanism.³ The symptoms experienced may be resolved pharmacologically or by means of an invasive therapy. Serious sequelae associated with SVT include heart failure and cardiac arrest.

For children with rare and mildly symptomatic episodes in whom SVT is easily terminated, the SVT may not warrant treatment. However, it may be advisable to offer medical therapy or transcatheter ablation as therapeutic options for children with episodes that are difficult to terminate, occur frequently, or occur during participation in athletics.⁴

Pathophysiology
SVT generally presents as one of three types: AVRT, which is also known as Wolff-Parkinson-White syndrome; atrioventricular nodal reentry tachycardia (AVNRT); and automatic tachycardia (AT).

AVRT, the most common type of SVT, comprises about 90% of pediatric cases. It is defined by the presence of one or more accessory conduction pathways that are anatomically separated from the normal cardiac conduction system.5 AVRT may be orthodromic (that is, the arrhythmia circuit proceeds down the AV node and retrograde up the accessory conduction pathway) or antedromic (ie, proceeding down the accessory pathway and up the AV node⁵; see figure.^6,7)

AVNRT, considered the second most common type of SVT in children, accounts for about 10% of pediatric cases. AVNRT is caused by an interaction between the two types of pathways within the AV node—one with a fast conduction time and a short refractory period, and the other with a slow conduction time and a long refractory period. AVNRT occurs when the antegrade conduction block in the fast pathway results in conduction over the slow pathway and back up the fast pathway, forming a microreentrant circuit.⁵

AT is the result of rapid depolarization from an automatic focus originating within the atria but outside the sinus node.³

Patient Presentation and History
The typical presentation of AVRT in children of school age includes palpitations, chest pain or tightness, dizziness, anxiety, decrease in exercise tolerance, easy fatigability, and/or shortness of breath.³ Onset is described as abrupt, while termination of SVT is described as slower because the catecholamine levels are typically elevated.⁴

The frequency and duration of SVT can vary greatly, from a few minutes to a few hours; it can occur as regularly as daily or as uncommonly as once or twice per year.⁴ Additionally, SVT symptoms can go unrecognized until a cardiac dysfunction develops. As for the patient in the case study, no apparent factor in her history was identified that may have induced SVT.

The differential diagnosis for SVT is broad, including sinus tachycardia, multifocal atrial tachycardia, and SVT with aberrancy.⁸ Additional considerations include stress, anxiety, hyperthyroidism, electrolyte abnormalities, and dehydration—any of which can present with a tachycardia response.⁴ Furthermore, clinicians are often unlikely to diagnose a child with any cardiac problem because chest pain is more commonly a presenting symptom of a pulmonary or musculoskeletal condition than a cardiac problem.³

Physical Examination
SVT can be diagnosed based on medical history and physical examination. During the physical examination, providers will assess the patient’s blood pressure and pulse, auscultate heart and lung sounds, assess the veins in the patient’s neck for different types of pulsations, and conduct cardiac maneuvers, including the Valsalva maneuver and carotid sinus massage.^9,10

Laboratory Work-up and Diagnosis
Three specific tests help clinicians monitor and evaluate a patient’s conduction system. ECG is important to assess the heart rhythm both at baseline and when symptoms are occurring, if possible.³ Ambulatory ECG (ie, Holter monitoring, event recorders) record the patient’s heart rhythm on a continuous basis.

An EPS, which is performed to classify the mechanism of SVT, is conducted by inserting one or more electrocatheters into the heart by way of the femoral vein or other peripheral vessel.³ Pacing and sensing electrodes at the ends of the catheters record local intracardiac electrical activity and timing information, providing a detailed analysis of the heart’s electrical activity. The EPS is critical to determine the presence of one or more extra electrical pathways within the heart and to localize it by region.^3,11 An ablation procedure may follow.

Management Options
SVT can be treated pharmacologically or nonpharmacologically. First-line pharmacologic options include certain beta-blockers (including atenolol and propranolol), digoxin, and calcium channel blockers. Second-line pharmacologic treatments include amiodarone, flecainide, and sotalol,⁴ all of which are contraindicated in children younger than 1 year because of these patients’ hemodynamic dependency on the heart and inability to generate stroke volume.³ Pharmacologic treatment of SVT is associated with a 68% success rate in children⁴ (see Table 1⁴).

For children in whom pharmacologic treatment is ineffective, an ablation procedure may be performed. Radiofrequency catheter ablation is currently considered first-line therapy for AVRT and AVNRT.¹² In this invasive procedure, intracardiac electrical mapping is performed and the initiating focus of the arrhythmia or the accessory electrical pathway that has been identified within the heart is destroyed by radiofrequency energy, delivered by electrocatheter. Ablations performed during the acute phase of SVT have a 95% success rate.^3,13

Cryoablation is a relatively new treatment in which liquid nitrous oxide is used to cool the catheter to subfreezing temperatures, enabling it to destroy the myocardial tissue by freezing.^3,14 The advantage of cryoablation is the option of reversible cooling, which allows the electrophysiologist to test the area first, confirming the accuracy of the apparent location accessory pathway.¹⁵

Noninvasive, nonpharmacologic interventions that increase the refractoriness of the AV node may be successful in terminating the tachyarrhythmia during episodes of SVT (see Table 2^3,9,13,16). They are used to terminate and diagnose tachydysrhythmias, increase parasympathetic tone, and slow conduction through the AV node.³

Patient Education
It is very important for health care providers to relieve parents’ and caregivers’ stress, anxiety, and uncertainty by educating them about the child’s cardiac condition of SVT. Information to convey include an understanding of what SVT is, what may cause it, what triggers the patient should avoid, what treatments are available and appropriate (including the maneuvers shown in Table 2), and what outcomes may be expected. An excellent patient/family education handout from the Children’s Hospitals and Clinics of Minnesota¹⁷ is available at www.childrensmn.org/Manuals/PFS/Condill/018303.pdf.

Follow-Up
Primary care providers must emphasize the importance of monitoring the patient’s progress, based on the severity of his or her SVT symptoms. The provider may choose to monitor the patient for a few weeks or a few months, assessing the frequency of arrhythmia recurrence and the heart rate, to adjust or substitute medications based on repeat ECG or Holter evaluations, and to plan further therapy, should the condition worsen.⁵

The Case Patient
One month after undergoing radiofrequency catheter ablation, the child presented to the pediatric cardiologist for follow-up. Since the procedure, she had been without any symptoms referable to the cardiovascular system. She denied experiencing any fast heart rate, palpitations, chest pain, shortness of breath, or dizziness. ECG demonstrated normal sinus rhythm.

Two years after undergoing radiofrequency ablation, the child is functioning at a normal activity level with no recurrence of SVT episodes.

Conclusion
The purpose of this case study is to improve primary care providers’ understanding of SVT in children and to convey the importance of identifying the condition in a timely manner and referring patients to a pediatric cardiologist or electrophysiologist. For most children affected by SVT, a regimen of pharmacologic and/or nonpharmacologic treatment—supported by detailed education for their parents and caregivers—can allow them to live a healthy, normal life.

A 6-year-old girl was brought by her parents to the emergency department (ED) with an elevated heart rate. According to the parents, the girl was carrying her younger sister when they both fell, landing on their buttocks. The child told them that her heart was beating fast, and the parents said she appeared to be on the verge of fainting.

They stated that their daughter was healthy and active; they denied previous episodes of shortness of breath, headache, weakness, tachycardia, syncope, or fatigue with exercise. Her caffeine intake, they claimed, was limited to one small cup of soda they allowed her each week.

Initial evaluation in the ED revealed an anxious child with tachycardia and shortness of breath. She presented with a temperature of 98.3°F (36.8°C); pulse, 210 beats/min; respirations, 33 breaths/min; blood pressure, 100/72 mm Hg; weight, 78 lb; height, 45 in; and BMI, 27.1. ECG revealed a heart rate exceeding 210 beats/min, and a pediatric cardiologist made a diagnosis of supraventricular tachycardia (SVT).

The pediatric cardiologist prescribed an adenosine IV drip, which successfully stabilized the child’s heart to sinus rhythm. After three hours in the ED, the patient was discharged with a stable heart rate of 100 beats/min. (It is well known that heart rate regulation changes significantly during development; this is most obvious in higher basal rates in infants and children, compared with adults.¹)

The parents were advised to administer atenolol 12.5 mg (one tablet) twice daily and to make a follow-up appointment with a pediatric electrophysiologist. (Although atenolol is not currently FDA approved for this use, a multicenter prospective randomized controlled trial comparing digoxin with beta-blockers for the treatment of SVT in children is presently under way.²)

At that appointment, the pediatric electrophysiologist provided information to the parents regarding the therapeutic options for SVT. The parents continued to administer atenolol to the child, as was deemed necessary until any accessory electrical pathway could be identified and, if so, an ablation procedure could be performed. They were uncertain how to proceed so long as their daughter experienced no recurrent episodes of SVT while receiving pharmacologic therapy.

However, six months after the initial episode, the child (then age 7) presented to the ED once again with recurrent SVT. The pediatric cardiologist ordered an adenosine IV drip, which resulted in successful conversion to sinus rhythm. The parents were instructed to increase the child’s atenolol dosage to 25 mg twice a day.

Six months later, after extensive research and consultation, the parents agreed to an ablation procedure in order to prevent further episodes of SVT. Upon their informed consent, the child was sent to a cardiac catheterization laboratory for an electrophysiology study (EPS), which confirmed the presence of an accessory pathway, as well as the diagnosis of atrioventricular reciprocating tachycardia (AVRT). The procedure was followed by radiofrequency catheter ablation to correct the 7-year-old patient’s accessory pathway–mediated reentry tachycardia.

Discussion
SVT, also known as paroxysmal supraventricular tachycardia (PSVT), is one of the most common symptomatic pediatric arrhythmias, affecting between one in 25,000 and one in 250 children.³ It is defined as rapid heart rhythm (140 to 240 beats/min) that is caused by the presence of additional electrical connections and/or congenital muscle fibers between the atrium and the ventricle or within the atrioventricular (AV) node that did not, for unknown reasons, separate completely during development.⁴ SVT can be triggered by physical or psychological stress automaticity.³

Approximately 50% of children with SVT present with a first episode before age 1. SVT usually occurs in early childhood, between ages 6 and 9.⁴ Almost 90% of pediatric patients with SVT are diagnosed with a reentry mechanism.³ The symptoms experienced may be resolved pharmacologically or by means of an invasive therapy. Serious sequelae associated with SVT include heart failure and cardiac arrest.

For children with rare and mildly symptomatic episodes in whom SVT is easily terminated, the SVT may not warrant treatment. However, it may be advisable to offer medical therapy or transcatheter ablation as therapeutic options for children with episodes that are difficult to terminate, occur frequently, or occur during participation in athletics.⁴

Pathophysiology
SVT generally presents as one of three types: AVRT, which is also known as Wolff-Parkinson-White syndrome; atrioventricular nodal reentry tachycardia (AVNRT); and automatic tachycardia (AT).

AVRT, the most common type of SVT, comprises about 90% of pediatric cases. It is defined by the presence of one or more accessory conduction pathways that are anatomically separated from the normal cardiac conduction system.5 AVRT may be orthodromic (that is, the arrhythmia circuit proceeds down the AV node and retrograde up the accessory conduction pathway) or antedromic (ie, proceeding down the accessory pathway and up the AV node⁵; see figure.^6,7)

AVNRT, considered the second most common type of SVT in children, accounts for about 10% of pediatric cases. AVNRT is caused by an interaction between the two types of pathways within the AV node—one with a fast conduction time and a short refractory period, and the other with a slow conduction time and a long refractory period. AVNRT occurs when the antegrade conduction block in the fast pathway results in conduction over the slow pathway and back up the fast pathway, forming a microreentrant circuit.⁵

AT is the result of rapid depolarization from an automatic focus originating within the atria but outside the sinus node.³

Patient Presentation and History
The typical presentation of AVRT in children of school age includes palpitations, chest pain or tightness, dizziness, anxiety, decrease in exercise tolerance, easy fatigability, and/or shortness of breath.³ Onset is described as abrupt, while termination of SVT is described as slower because the catecholamine levels are typically elevated.⁴

The frequency and duration of SVT can vary greatly, from a few minutes to a few hours; it can occur as regularly as daily or as uncommonly as once or twice per year.⁴ Additionally, SVT symptoms can go unrecognized until a cardiac dysfunction develops. As for the patient in the case study, no apparent factor in her history was identified that may have induced SVT.

The differential diagnosis for SVT is broad, including sinus tachycardia, multifocal atrial tachycardia, and SVT with aberrancy.⁸ Additional considerations include stress, anxiety, hyperthyroidism, electrolyte abnormalities, and dehydration—any of which can present with a tachycardia response.⁴ Furthermore, clinicians are often unlikely to diagnose a child with any cardiac problem because chest pain is more commonly a presenting symptom of a pulmonary or musculoskeletal condition than a cardiac problem.³

Physical Examination
SVT can be diagnosed based on medical history and physical examination. During the physical examination, providers will assess the patient’s blood pressure and pulse, auscultate heart and lung sounds, assess the veins in the patient’s neck for different types of pulsations, and conduct cardiac maneuvers, including the Valsalva maneuver and carotid sinus massage.^9,10

Laboratory Work-up and Diagnosis
Three specific tests help clinicians monitor and evaluate a patient’s conduction system. ECG is important to assess the heart rhythm both at baseline and when symptoms are occurring, if possible.³ Ambulatory ECG (ie, Holter monitoring, event recorders) record the patient’s heart rhythm on a continuous basis.

An EPS, which is performed to classify the mechanism of SVT, is conducted by inserting one or more electrocatheters into the heart by way of the femoral vein or other peripheral vessel.³ Pacing and sensing electrodes at the ends of the catheters record local intracardiac electrical activity and timing information, providing a detailed analysis of the heart’s electrical activity. The EPS is critical to determine the presence of one or more extra electrical pathways within the heart and to localize it by region.^3,11 An ablation procedure may follow.

Management Options
SVT can be treated pharmacologically or nonpharmacologically. First-line pharmacologic options include certain beta-blockers (including atenolol and propranolol), digoxin, and calcium channel blockers. Second-line pharmacologic treatments include amiodarone, flecainide, and sotalol,⁴ all of which are contraindicated in children younger than 1 year because of these patients’ hemodynamic dependency on the heart and inability to generate stroke volume.³ Pharmacologic treatment of SVT is associated with a 68% success rate in children⁴ (see Table 1⁴).

For children in whom pharmacologic treatment is ineffective, an ablation procedure may be performed. Radiofrequency catheter ablation is currently considered first-line therapy for AVRT and AVNRT.¹² In this invasive procedure, intracardiac electrical mapping is performed and the initiating focus of the arrhythmia or the accessory electrical pathway that has been identified within the heart is destroyed by radiofrequency energy, delivered by electrocatheter. Ablations performed during the acute phase of SVT have a 95% success rate.^3,13

Cryoablation is a relatively new treatment in which liquid nitrous oxide is used to cool the catheter to subfreezing temperatures, enabling it to destroy the myocardial tissue by freezing.^3,14 The advantage of cryoablation is the option of reversible cooling, which allows the electrophysiologist to test the area first, confirming the accuracy of the apparent location accessory pathway.¹⁵

Noninvasive, nonpharmacologic interventions that increase the refractoriness of the AV node may be successful in terminating the tachyarrhythmia during episodes of SVT (see Table 2^3,9,13,16). They are used to terminate and diagnose tachydysrhythmias, increase parasympathetic tone, and slow conduction through the AV node.³

Patient Education
It is very important for health care providers to relieve parents’ and caregivers’ stress, anxiety, and uncertainty by educating them about the child’s cardiac condition of SVT. Information to convey include an understanding of what SVT is, what may cause it, what triggers the patient should avoid, what treatments are available and appropriate (including the maneuvers shown in Table 2), and what outcomes may be expected. An excellent patient/family education handout from the Children’s Hospitals and Clinics of Minnesota¹⁷ is available at www.childrensmn.org/Manuals/PFS/Condill/018303.pdf.

Follow-Up
Primary care providers must emphasize the importance of monitoring the patient’s progress, based on the severity of his or her SVT symptoms. The provider may choose to monitor the patient for a few weeks or a few months, assessing the frequency of arrhythmia recurrence and the heart rate, to adjust or substitute medications based on repeat ECG or Holter evaluations, and to plan further therapy, should the condition worsen.⁵

The Case Patient
One month after undergoing radiofrequency catheter ablation, the child presented to the pediatric cardiologist for follow-up. Since the procedure, she had been without any symptoms referable to the cardiovascular system. She denied experiencing any fast heart rate, palpitations, chest pain, shortness of breath, or dizziness. ECG demonstrated normal sinus rhythm.

Two years after undergoing radiofrequency ablation, the child is functioning at a normal activity level with no recurrence of SVT episodes.

Conclusion
The purpose of this case study is to improve primary care providers’ understanding of SVT in children and to convey the importance of identifying the condition in a timely manner and referring patients to a pediatric cardiologist or electrophysiologist. For most children affected by SVT, a regimen of pharmacologic and/or nonpharmacologic treatment—supported by detailed education for their parents and caregivers—can allow them to live a healthy, normal life.

When a screening mammogram isn’t enough

A LUMP IN THE BREAST was discovered by a woman in her mid-40s. She underwent a screening (rather than a diagnostic) mammogram; no abnormalities were reported. An ultrasound ordered when the woman returned to her physician the following year noted problems. However, the report that was faxed to the physician never reached him, and no follow-up was done.

A year later, the patient made a follow-up appointment on her own initiative. A diagnostic mammogram and surgical biopsy revealed advanced cancer of the left breast. Vacuum-assisted core biopsy and clip localization performed shortly thereafter identified infiltrating ductal carcinoma.

The patient underwent neoadjuvant chemotherapy, resulting in complications and hospitalization. She subsequently had additional chemotherapy and radiation treatment.

PLAINTIFF’S CLAIM Immediate treatment would have improved the patient’s chances of cure.

THE DEFENSE No information about the defense is available.

VERDICT $575,000 settlement in South Carolina under the Federal Tort Claims Act, plus a $5,000 settlement with a hospital.

COMMENT A couple of lessons from this unfortunate case: Make sure a diagnostic (not screening) mammogram is ordered when evaluating a breast mass, and maintain a tickler file for critical lab and imaging results.

Insurance denied, appeal delayed, treatment of appendicitis deferred

ABDOMINAL PAIN SEVERE ENOUGH TO AWAKEN HER prompted a 48-year-old woman to contact her physician, who saw her 2 days later. The doctor performed an ultrasound examination, which ruled out gallstones, and ordered a computed tomography (CT) scan of the pelvis for the following day.

After the patient was injected with contrast medium for the scan, it was learned that her insurer had refused to approve the test. The patient’s pain persisted, and her doctor prescribed a pain reliever for a presumed pulled muscle. A week later, the doctor appealed the insurer’s denial of the CT scan in writing. The insurer responded that the scan would be approved if a fecal blood test proved negative.

Test results were submitted 4 days later; the CT scan was approved and performed a little more than 3 weeks after the initial order. The patient was diagnosed with appendicitis and underwent emergency surgery, including removal of part of her colon and bowel. Eight days in the hospital and a lengthy recovery followed.

PLAINTIFF’S CLAIM The physician was negligent in failing to follow up promptly on the insurer’s denial of approval for the CT scan.

DOCTOR’S DEFENSE The physician claimed that he had ordered the proper test in a timely manner; denial of approval by the insurer delayed treatment.

VERDICT $1.3 million Kentucky verdict against the physician after the plaintiff settled with the insurer.

COMMENT Ouch! This outcome is one we all fear—the insurer denying approval for a test and the physician bearing the brunt of a malpractice claim. When in doubt, get the test done and sort out the paperwork later.

Undiagnosed heart condition leads to brain injury

A 14-YEAR-OLD BOY collapsed while participating in a rodeo branding event. He was revived and taken to an emergency room (ER), where a physician evaluated him and admitted him to the hospital for overnight monitoring. The heart monitor recorded QT intervals suggesting long QT syndrome, a rare congenital condition that can lead to fainting and, occasionally, death from cardiac arrhythmias. The condition wasn’t diagnosed at the time.

A year and a half later, the patient collapsed again, this time during school wrestling practice. This more severe event resulted in anoxic brain injury, which left the patient disabled and in need of assistance with activities of daily living.

PLAINTIFF’S CLAIM The ER physician failed to diagnose congenital long QT syndrome. Proper diagnosis and treatment after the first incident could have prevented the second incident.

THE DEFENSE No information about the defense is available.

VERDICT Confidential Wyoming settlement, which included a provision that the defendant’s insurer provide inservice training on sudden arrhythmias and long QT syndrome for local doctors and other health care providers.

COMMENT Remember the zebras, as well as the horses, particularly when evaluating a patient for an unusual and potentially life-altering problem. Although syncope may be common in elders, such events in teenagers should prompt a comprehensive and meticulous evaluation.

Suicide follows antidepressant use

A 58-YEAR-OLD MAN with unexplained weight loss, diminished appetite, increased stress, edginess, and decreased libido sought care from his physician. The doctor diagnosed depression and prescribed escitalopram, 10 mg per day. He gave the patient a 5-week supply of sample medication with no warning literature or product information. Twenty days later, the patient hanged himself at home.

PLAINTIFF’S CLAIM The physician wrongly diagnosed depression; he shouldn’t have given the patient escitalopram because the US Food and Drug Administration (FDA) has issued an advisory concerning increased risk of suicide for adults treated with antidepressants. Neither the patient nor his family was informed about the possible side effects of escitalopram.

THE DEFENSE The diagnosis of depression was proper; nothing the defendants did or failed to do contributed to the patient’s death.

VERDICT Ohio defense verdict.

COMMENT Given the FDA’s black-box warning, it is imperative that we counsel and document concerning the risk of suicide when initiating therapy for depression.

When a screening mammogram isn’t enough

A LUMP IN THE BREAST was discovered by a woman in her mid-40s. She underwent a screening (rather than a diagnostic) mammogram; no abnormalities were reported. An ultrasound ordered when the woman returned to her physician the following year noted problems. However, the report that was faxed to the physician never reached him, and no follow-up was done.

A year later, the patient made a follow-up appointment on her own initiative. A diagnostic mammogram and surgical biopsy revealed advanced cancer of the left breast. Vacuum-assisted core biopsy and clip localization performed shortly thereafter identified infiltrating ductal carcinoma.

The patient underwent neoadjuvant chemotherapy, resulting in complications and hospitalization. She subsequently had additional chemotherapy and radiation treatment.

PLAINTIFF’S CLAIM Immediate treatment would have improved the patient’s chances of cure.

THE DEFENSE No information about the defense is available.

VERDICT $575,000 settlement in South Carolina under the Federal Tort Claims Act, plus a $5,000 settlement with a hospital.

COMMENT A couple of lessons from this unfortunate case: Make sure a diagnostic (not screening) mammogram is ordered when evaluating a breast mass, and maintain a tickler file for critical lab and imaging results.

Insurance denied, appeal delayed, treatment of appendicitis deferred

ABDOMINAL PAIN SEVERE ENOUGH TO AWAKEN HER prompted a 48-year-old woman to contact her physician, who saw her 2 days later. The doctor performed an ultrasound examination, which ruled out gallstones, and ordered a computed tomography (CT) scan of the pelvis for the following day.

After the patient was injected with contrast medium for the scan, it was learned that her insurer had refused to approve the test. The patient’s pain persisted, and her doctor prescribed a pain reliever for a presumed pulled muscle. A week later, the doctor appealed the insurer’s denial of the CT scan in writing. The insurer responded that the scan would be approved if a fecal blood test proved negative.

Test results were submitted 4 days later; the CT scan was approved and performed a little more than 3 weeks after the initial order. The patient was diagnosed with appendicitis and underwent emergency surgery, including removal of part of her colon and bowel. Eight days in the hospital and a lengthy recovery followed.

PLAINTIFF’S CLAIM The physician was negligent in failing to follow up promptly on the insurer’s denial of approval for the CT scan.

DOCTOR’S DEFENSE The physician claimed that he had ordered the proper test in a timely manner; denial of approval by the insurer delayed treatment.

VERDICT $1.3 million Kentucky verdict against the physician after the plaintiff settled with the insurer.

COMMENT Ouch! This outcome is one we all fear—the insurer denying approval for a test and the physician bearing the brunt of a malpractice claim. When in doubt, get the test done and sort out the paperwork later.

Undiagnosed heart condition leads to brain injury

A 14-YEAR-OLD BOY collapsed while participating in a rodeo branding event. He was revived and taken to an emergency room (ER), where a physician evaluated him and admitted him to the hospital for overnight monitoring. The heart monitor recorded QT intervals suggesting long QT syndrome, a rare congenital condition that can lead to fainting and, occasionally, death from cardiac arrhythmias. The condition wasn’t diagnosed at the time.

A year and a half later, the patient collapsed again, this time during school wrestling practice. This more severe event resulted in anoxic brain injury, which left the patient disabled and in need of assistance with activities of daily living.

PLAINTIFF’S CLAIM The ER physician failed to diagnose congenital long QT syndrome. Proper diagnosis and treatment after the first incident could have prevented the second incident.

THE DEFENSE No information about the defense is available.

VERDICT Confidential Wyoming settlement, which included a provision that the defendant’s insurer provide inservice training on sudden arrhythmias and long QT syndrome for local doctors and other health care providers.

COMMENT Remember the zebras, as well as the horses, particularly when evaluating a patient for an unusual and potentially life-altering problem. Although syncope may be common in elders, such events in teenagers should prompt a comprehensive and meticulous evaluation.

Suicide follows antidepressant use

A 58-YEAR-OLD MAN with unexplained weight loss, diminished appetite, increased stress, edginess, and decreased libido sought care from his physician. The doctor diagnosed depression and prescribed escitalopram, 10 mg per day. He gave the patient a 5-week supply of sample medication with no warning literature or product information. Twenty days later, the patient hanged himself at home.

PLAINTIFF’S CLAIM The physician wrongly diagnosed depression; he shouldn’t have given the patient escitalopram because the US Food and Drug Administration (FDA) has issued an advisory concerning increased risk of suicide for adults treated with antidepressants. Neither the patient nor his family was informed about the possible side effects of escitalopram.

THE DEFENSE The diagnosis of depression was proper; nothing the defendants did or failed to do contributed to the patient’s death.

VERDICT Ohio defense verdict.

COMMENT Given the FDA’s black-box warning, it is imperative that we counsel and document concerning the risk of suicide when initiating therapy for depression.

When a screening mammogram isn’t enough

A LUMP IN THE BREAST was discovered by a woman in her mid-40s. She underwent a screening (rather than a diagnostic) mammogram; no abnormalities were reported. An ultrasound ordered when the woman returned to her physician the following year noted problems. However, the report that was faxed to the physician never reached him, and no follow-up was done.

A year later, the patient made a follow-up appointment on her own initiative. A diagnostic mammogram and surgical biopsy revealed advanced cancer of the left breast. Vacuum-assisted core biopsy and clip localization performed shortly thereafter identified infiltrating ductal carcinoma.

The patient underwent neoadjuvant chemotherapy, resulting in complications and hospitalization. She subsequently had additional chemotherapy and radiation treatment.

PLAINTIFF’S CLAIM Immediate treatment would have improved the patient’s chances of cure.

THE DEFENSE No information about the defense is available.

VERDICT $575,000 settlement in South Carolina under the Federal Tort Claims Act, plus a $5,000 settlement with a hospital.

COMMENT A couple of lessons from this unfortunate case: Make sure a diagnostic (not screening) mammogram is ordered when evaluating a breast mass, and maintain a tickler file for critical lab and imaging results.

Insurance denied, appeal delayed, treatment of appendicitis deferred

ABDOMINAL PAIN SEVERE ENOUGH TO AWAKEN HER prompted a 48-year-old woman to contact her physician, who saw her 2 days later. The doctor performed an ultrasound examination, which ruled out gallstones, and ordered a computed tomography (CT) scan of the pelvis for the following day.

After the patient was injected with contrast medium for the scan, it was learned that her insurer had refused to approve the test. The patient’s pain persisted, and her doctor prescribed a pain reliever for a presumed pulled muscle. A week later, the doctor appealed the insurer’s denial of the CT scan in writing. The insurer responded that the scan would be approved if a fecal blood test proved negative.

Test results were submitted 4 days later; the CT scan was approved and performed a little more than 3 weeks after the initial order. The patient was diagnosed with appendicitis and underwent emergency surgery, including removal of part of her colon and bowel. Eight days in the hospital and a lengthy recovery followed.

PLAINTIFF’S CLAIM The physician was negligent in failing to follow up promptly on the insurer’s denial of approval for the CT scan.

DOCTOR’S DEFENSE The physician claimed that he had ordered the proper test in a timely manner; denial of approval by the insurer delayed treatment.

VERDICT $1.3 million Kentucky verdict against the physician after the plaintiff settled with the insurer.

COMMENT Ouch! This outcome is one we all fear—the insurer denying approval for a test and the physician bearing the brunt of a malpractice claim. When in doubt, get the test done and sort out the paperwork later.

Undiagnosed heart condition leads to brain injury

A 14-YEAR-OLD BOY collapsed while participating in a rodeo branding event. He was revived and taken to an emergency room (ER), where a physician evaluated him and admitted him to the hospital for overnight monitoring. The heart monitor recorded QT intervals suggesting long QT syndrome, a rare congenital condition that can lead to fainting and, occasionally, death from cardiac arrhythmias. The condition wasn’t diagnosed at the time.

A year and a half later, the patient collapsed again, this time during school wrestling practice. This more severe event resulted in anoxic brain injury, which left the patient disabled and in need of assistance with activities of daily living.

PLAINTIFF’S CLAIM The ER physician failed to diagnose congenital long QT syndrome. Proper diagnosis and treatment after the first incident could have prevented the second incident.

THE DEFENSE No information about the defense is available.

VERDICT Confidential Wyoming settlement, which included a provision that the defendant’s insurer provide inservice training on sudden arrhythmias and long QT syndrome for local doctors and other health care providers.

COMMENT Remember the zebras, as well as the horses, particularly when evaluating a patient for an unusual and potentially life-altering problem. Although syncope may be common in elders, such events in teenagers should prompt a comprehensive and meticulous evaluation.

Suicide follows antidepressant use

A 58-YEAR-OLD MAN with unexplained weight loss, diminished appetite, increased stress, edginess, and decreased libido sought care from his physician. The doctor diagnosed depression and prescribed escitalopram, 10 mg per day. He gave the patient a 5-week supply of sample medication with no warning literature or product information. Twenty days later, the patient hanged himself at home.

PLAINTIFF’S CLAIM The physician wrongly diagnosed depression; he shouldn’t have given the patient escitalopram because the US Food and Drug Administration (FDA) has issued an advisory concerning increased risk of suicide for adults treated with antidepressants. Neither the patient nor his family was informed about the possible side effects of escitalopram.

THE DEFENSE The diagnosis of depression was proper; nothing the defendants did or failed to do contributed to the patient’s death.

VERDICT Ohio defense verdict.

COMMENT Given the FDA’s black-box warning, it is imperative that we counsel and document concerning the risk of suicide when initiating therapy for depression.

pdnews@elsevier.com

Persistent hives, or chronic urticaria, can be challenging to diagnose, treat, and manage. This condition is also somewhat common—I see it often at Miami Children's Hospital.

Persistent hives are distinctive from an acute presentation because they typically last 6 weeks or longer. They are not only frustrating for physicians—the etiology is identified in only a minority of affected children, but this disease can significantly impair quality of life for patients and their families.

Infections are a common cause of persistent hives. Other conditions to consider in your differential diagnosis include drug and food allergies, physical urticaria (caused by exposure to heat or cold), autoimmune disease, erythema multiforme minor, and dermatographism. Dermatographism is a condition in which stroking or scratching the skin with a dull instrument causes a raised welt, or wheal, to appear because of increased mast cell activation. The skin generally appears pale in the center with a red flare on either side. A physical allergy causes this type of urticaria.

In conjunction with the physical examination, review all medications taken in the last 6 weeks, including but not limited to new agents. Also ask the patient and parents about the type of foods the child consumed within the last several weeks with regularity.

A long-acting antihistamine, with 24-hour coverage, can be helpful. For some children with persistent hives, you may need to think outside the box and prescribe both a short-acting and long-acting antihistamine. The short-acting agent can be used to control an acute presentation while the long-acting drug provides maintenance.

If the condition improves with antihistamines and the hives are not interfering with quality of life or sleep, then you should feel comfortable treating the child.

If antihistamine therapy is not helpful, the lesions are interfering with lifestyle or sleep, or the patient complains of swelling, it is appropriate to refer the child to a specialist for additional work-up. Swelling is often a presenting sign with chronic urticaria, and typically it is generalized or affects the hands or face. The swelling often makes the patient and family uncomfortable.

If you decide to order laboratory testing prior to a specialist referral, a complete blood count, an erythrocyte sedimentation rate assay, a liver function test, and thyroid studies can be useful. But you also can simply refer the patient to an allergist or immunologist, and we can order the testing.

In contrast, a food-specific immunoglobulin G test is not helpful for the assessment of a child with persistent hives. This laboratory assay should not be ordered because it only adds to the cost of the diagnosis without aiding in the clinical diagnosis.

If you are fortunate and can identify the cause of the chronic urticaria—which only occurs in 5%-20% of cases—it calls for strict avoidance. This is another aspect where persistent hives differ from an acute presentation, because the etiology of an acute condition is more frequently found and subsequently may be avoided by the child.

Also educate the patient that persistent hives can be daily or episodic. Again, if the patient is lucky, the lesions resolve in less than 1 year. However, inform the patient that—in some cases—the hives can persist for several years.

pdnews@elsevier.com

Persistent hives, or chronic urticaria, can be challenging to diagnose, treat, and manage. This condition is also somewhat common—I see it often at Miami Children's Hospital.

Persistent hives are distinctive from an acute presentation because they typically last 6 weeks or longer. They are not only frustrating for physicians—the etiology is identified in only a minority of affected children, but this disease can significantly impair quality of life for patients and their families.

Infections are a common cause of persistent hives. Other conditions to consider in your differential diagnosis include drug and food allergies, physical urticaria (caused by exposure to heat or cold), autoimmune disease, erythema multiforme minor, and dermatographism. Dermatographism is a condition in which stroking or scratching the skin with a dull instrument causes a raised welt, or wheal, to appear because of increased mast cell activation. The skin generally appears pale in the center with a red flare on either side. A physical allergy causes this type of urticaria.

In conjunction with the physical examination, review all medications taken in the last 6 weeks, including but not limited to new agents. Also ask the patient and parents about the type of foods the child consumed within the last several weeks with regularity.

A long-acting antihistamine, with 24-hour coverage, can be helpful. For some children with persistent hives, you may need to think outside the box and prescribe both a short-acting and long-acting antihistamine. The short-acting agent can be used to control an acute presentation while the long-acting drug provides maintenance.

If the condition improves with antihistamines and the hives are not interfering with quality of life or sleep, then you should feel comfortable treating the child.

If antihistamine therapy is not helpful, the lesions are interfering with lifestyle or sleep, or the patient complains of swelling, it is appropriate to refer the child to a specialist for additional work-up. Swelling is often a presenting sign with chronic urticaria, and typically it is generalized or affects the hands or face. The swelling often makes the patient and family uncomfortable.

If you decide to order laboratory testing prior to a specialist referral, a complete blood count, an erythrocyte sedimentation rate assay, a liver function test, and thyroid studies can be useful. But you also can simply refer the patient to an allergist or immunologist, and we can order the testing.

In contrast, a food-specific immunoglobulin G test is not helpful for the assessment of a child with persistent hives. This laboratory assay should not be ordered because it only adds to the cost of the diagnosis without aiding in the clinical diagnosis.

If you are fortunate and can identify the cause of the chronic urticaria—which only occurs in 5%-20% of cases—it calls for strict avoidance. This is another aspect where persistent hives differ from an acute presentation, because the etiology of an acute condition is more frequently found and subsequently may be avoided by the child.

Also educate the patient that persistent hives can be daily or episodic. Again, if the patient is lucky, the lesions resolve in less than 1 year. However, inform the patient that—in some cases—the hives can persist for several years.

pdnews@elsevier.com

Persistent hives, or chronic urticaria, can be challenging to diagnose, treat, and manage. This condition is also somewhat common—I see it often at Miami Children's Hospital.

Persistent hives are distinctive from an acute presentation because they typically last 6 weeks or longer. They are not only frustrating for physicians—the etiology is identified in only a minority of affected children, but this disease can significantly impair quality of life for patients and their families.

Infections are a common cause of persistent hives. Other conditions to consider in your differential diagnosis include drug and food allergies, physical urticaria (caused by exposure to heat or cold), autoimmune disease, erythema multiforme minor, and dermatographism. Dermatographism is a condition in which stroking or scratching the skin with a dull instrument causes a raised welt, or wheal, to appear because of increased mast cell activation. The skin generally appears pale in the center with a red flare on either side. A physical allergy causes this type of urticaria.

In conjunction with the physical examination, review all medications taken in the last 6 weeks, including but not limited to new agents. Also ask the patient and parents about the type of foods the child consumed within the last several weeks with regularity.

A long-acting antihistamine, with 24-hour coverage, can be helpful. For some children with persistent hives, you may need to think outside the box and prescribe both a short-acting and long-acting antihistamine. The short-acting agent can be used to control an acute presentation while the long-acting drug provides maintenance.

If the condition improves with antihistamines and the hives are not interfering with quality of life or sleep, then you should feel comfortable treating the child.

If antihistamine therapy is not helpful, the lesions are interfering with lifestyle or sleep, or the patient complains of swelling, it is appropriate to refer the child to a specialist for additional work-up. Swelling is often a presenting sign with chronic urticaria, and typically it is generalized or affects the hands or face. The swelling often makes the patient and family uncomfortable.

If you decide to order laboratory testing prior to a specialist referral, a complete blood count, an erythrocyte sedimentation rate assay, a liver function test, and thyroid studies can be useful. But you also can simply refer the patient to an allergist or immunologist, and we can order the testing.

In contrast, a food-specific immunoglobulin G test is not helpful for the assessment of a child with persistent hives. This laboratory assay should not be ordered because it only adds to the cost of the diagnosis without aiding in the clinical diagnosis.

If you are fortunate and can identify the cause of the chronic urticaria—which only occurs in 5%-20% of cases—it calls for strict avoidance. This is another aspect where persistent hives differ from an acute presentation, because the etiology of an acute condition is more frequently found and subsequently may be avoided by the child.

Also educate the patient that persistent hives can be daily or episodic. Again, if the patient is lucky, the lesions resolve in less than 1 year. However, inform the patient that—in some cases—the hives can persist for several years.

In the wake of a study that showed a 70% spike in the rate of VTE in pediatric hospitals, pediatric hospitalists and others are calling for a deeper analysis of the data.

The seven-year, multicenter study measured 11,337 hospitalized patients under the age of 18. Researchers found the annual rate of VTE increased by 70%, to 58 cases from 34 cases per 10,000 (P<0.001) (Pediatrics 2009;124(4):1001-1008). Several pediatricians note that the increase looks outsized because there has been little research on the topic over the past decade. Those interviewed say they expect more research in the future to define the breadth of the problem and potential solutions.

“I don’t think we think there’s been a seven-fold increase,” says Janna Journeycake, MD, MSCS, director of the Hemophilia and Thrombosis Program at Children's Medical Center, University of Texas Southwestern Medical Center at Dallas. “It was there all along. We just didn’t know how to recognize it.”

Mark Shen, MD, medical director of hospital medicine at Dell Children’s Medical Center in Austin, Texas, and The Hospitalist's pediatric editor, attributes a large part of the study’s findings to more awareness of VTE in the pediatric community and increases in serious bone and joint infections that lead to more central lines, a risk factor for VTE. Dr. Shen also points out that as physicians learn more about pediatric VTE, it is expected that the rate of its incidence will increase. “Before, we wouldn’t look for signs of a clot unless there were physical signs of swelling, discomfort, or shortness of breath,” he adds. “Now we are much quicker to go and do an ultrasound or look for some kind of thromboembolism.”

Dr. Journeycake sees pediatric hospitalists as the vanguard in moving forward, as long as they stay vigilant to recognize the warning signs. “The job of the hospitalist is to recognize the certain medical conditions in which VTE are most likely,” she says. “They are going to be the most critically ill kids, the ones with deep-seated infection, such as osteomyelitis, mastoiditis. … Those are going to be children with central venous catheters. Hospitalists need to realize this complication exists.”

In the wake of a study that showed a 70% spike in the rate of VTE in pediatric hospitals, pediatric hospitalists and others are calling for a deeper analysis of the data.

The seven-year, multicenter study measured 11,337 hospitalized patients under the age of 18. Researchers found the annual rate of VTE increased by 70%, to 58 cases from 34 cases per 10,000 (P<0.001) (Pediatrics 2009;124(4):1001-1008). Several pediatricians note that the increase looks outsized because there has been little research on the topic over the past decade. Those interviewed say they expect more research in the future to define the breadth of the problem and potential solutions.

“I don’t think we think there’s been a seven-fold increase,” says Janna Journeycake, MD, MSCS, director of the Hemophilia and Thrombosis Program at Children's Medical Center, University of Texas Southwestern Medical Center at Dallas. “It was there all along. We just didn’t know how to recognize it.”

Mark Shen, MD, medical director of hospital medicine at Dell Children’s Medical Center in Austin, Texas, and The Hospitalist's pediatric editor, attributes a large part of the study’s findings to more awareness of VTE in the pediatric community and increases in serious bone and joint infections that lead to more central lines, a risk factor for VTE. Dr. Shen also points out that as physicians learn more about pediatric VTE, it is expected that the rate of its incidence will increase. “Before, we wouldn’t look for signs of a clot unless there were physical signs of swelling, discomfort, or shortness of breath,” he adds. “Now we are much quicker to go and do an ultrasound or look for some kind of thromboembolism.”

Dr. Journeycake sees pediatric hospitalists as the vanguard in moving forward, as long as they stay vigilant to recognize the warning signs. “The job of the hospitalist is to recognize the certain medical conditions in which VTE are most likely,” she says. “They are going to be the most critically ill kids, the ones with deep-seated infection, such as osteomyelitis, mastoiditis. … Those are going to be children with central venous catheters. Hospitalists need to realize this complication exists.”

In the wake of a study that showed a 70% spike in the rate of VTE in pediatric hospitals, pediatric hospitalists and others are calling for a deeper analysis of the data.

The seven-year, multicenter study measured 11,337 hospitalized patients under the age of 18. Researchers found the annual rate of VTE increased by 70%, to 58 cases from 34 cases per 10,000 (P<0.001) (Pediatrics 2009;124(4):1001-1008). Several pediatricians note that the increase looks outsized because there has been little research on the topic over the past decade. Those interviewed say they expect more research in the future to define the breadth of the problem and potential solutions.

“I don’t think we think there’s been a seven-fold increase,” says Janna Journeycake, MD, MSCS, director of the Hemophilia and Thrombosis Program at Children's Medical Center, University of Texas Southwestern Medical Center at Dallas. “It was there all along. We just didn’t know how to recognize it.”

Mark Shen, MD, medical director of hospital medicine at Dell Children’s Medical Center in Austin, Texas, and The Hospitalist's pediatric editor, attributes a large part of the study’s findings to more awareness of VTE in the pediatric community and increases in serious bone and joint infections that lead to more central lines, a risk factor for VTE. Dr. Shen also points out that as physicians learn more about pediatric VTE, it is expected that the rate of its incidence will increase. “Before, we wouldn’t look for signs of a clot unless there were physical signs of swelling, discomfort, or shortness of breath,” he adds. “Now we are much quicker to go and do an ultrasound or look for some kind of thromboembolism.”

Dr. Journeycake sees pediatric hospitalists as the vanguard in moving forward, as long as they stay vigilant to recognize the warning signs. “The job of the hospitalist is to recognize the certain medical conditions in which VTE are most likely,” she says. “They are going to be the most critically ill kids, the ones with deep-seated infection, such as osteomyelitis, mastoiditis. … Those are going to be children with central venous catheters. Hospitalists need to realize this complication exists.”

Three medical centers have been nationally recognized for innovative approaches to preventing DVT and its potentially fatal complications. Central to each of the prevention strategies is a risk assessment tool that is easy to use, built directly into routine care, and linked directly to guideline-recommended choices for prophylaxis.

The North American Thrombosis Forum (NATF), in coordination with the pharmaceutical company Eisai Inc., recognized the following centers with the first DVTeamCare Hospital Award:

• The University of California at San Diego Medical Center was awarded as a representative of medical centers with more than 200 beds. The hospital embedded its VTE prevention protocol into admission, transfer, and perioperative order sets across all medical and surgical services, says Gregory A. Maynard, MD, chief of the division of hospital medicine. The protocol flags three levels of DVT risk, notes possible contraindications for a particular kind of patient, and presents a set of options for guideline-recommended prophylaxis. The protocol can be paper- or computer-based.

 

• The Johns Hopkins Hospital in Baltimore, also awarded as a representative for medical centers with more than 200 beds, developed a mandatory computer-based decision support system to facilitate specialty-specific risk factor assessment and the application of risk-appropriate VTE prophylaxis.

 

• The Washington, D.C., Veterans Affairs Medical Center won in the category representing medical centers with fewer than 200 beds. The hospital designed a seven-step process that walks providers through an evidence-based risk-factor assessment to determine appropriate thromboprophylactic therapy. 

The DVTeamCare Hospital Award reflects NATF's goal of enhancing thrombosis education, prevention, diagnosis, and treatment to improve patient outcomes, says NATF Executive Director Ilene Sussman, PhD.

Dr. Maynard and his UCSD colleagues have made their DVT prophylaxis toolkit available to other hospitalists wanting to lead similar efforts in their own hospital. The toolkit is posted both on the AHRQ and SHM Web sites.

"SHM and AHRQ should feel proud about this because we were one of the first places to do this successfully at such a high level," Dr. Maynard says. "We partnered with others and with SHM to build similar toolkits. SHM built VTE prevention collaboratives that enroll hospitalist leaders and mentor them through the process of VTE prevention performance improvement, tracking results longitudinally. Divya Shroff and her group in Washington, D.C., were enrolled in that VTE prevention collaborative. Their team won an award in VTE prevention by following the road map and by coming up with a good order set for DVT prevention that could be used in their VA hospital and in many other VAs across the country. I think that speaks to the strength of the concepts that we're using."

Each of the award-winning protocols will be presented at an NATF-sponsored program April 9 at Harvard Medical School in Boston. After the presentation, the winning protocols and implementation plans will be available at www.DVTeamCareAward.com to help other hospitals enhance their efforts to prevent DVT.

Three medical centers have been nationally recognized for innovative approaches to preventing DVT and its potentially fatal complications. Central to each of the prevention strategies is a risk assessment tool that is easy to use, built directly into routine care, and linked directly to guideline-recommended choices for prophylaxis.

The North American Thrombosis Forum (NATF), in coordination with the pharmaceutical company Eisai Inc., recognized the following centers with the first DVTeamCare Hospital Award:

• The University of California at San Diego Medical Center was awarded as a representative of medical centers with more than 200 beds. The hospital embedded its VTE prevention protocol into admission, transfer, and perioperative order sets across all medical and surgical services, says Gregory A. Maynard, MD, chief of the division of hospital medicine. The protocol flags three levels of DVT risk, notes possible contraindications for a particular kind of patient, and presents a set of options for guideline-recommended prophylaxis. The protocol can be paper- or computer-based.

 

• The Johns Hopkins Hospital in Baltimore, also awarded as a representative for medical centers with more than 200 beds, developed a mandatory computer-based decision support system to facilitate specialty-specific risk factor assessment and the application of risk-appropriate VTE prophylaxis.

 

• The Washington, D.C., Veterans Affairs Medical Center won in the category representing medical centers with fewer than 200 beds. The hospital designed a seven-step process that walks providers through an evidence-based risk-factor assessment to determine appropriate thromboprophylactic therapy. 

The DVTeamCare Hospital Award reflects NATF's goal of enhancing thrombosis education, prevention, diagnosis, and treatment to improve patient outcomes, says NATF Executive Director Ilene Sussman, PhD.

Dr. Maynard and his UCSD colleagues have made their DVT prophylaxis toolkit available to other hospitalists wanting to lead similar efforts in their own hospital. The toolkit is posted both on the AHRQ and SHM Web sites.

"SHM and AHRQ should feel proud about this because we were one of the first places to do this successfully at such a high level," Dr. Maynard says. "We partnered with others and with SHM to build similar toolkits. SHM built VTE prevention collaboratives that enroll hospitalist leaders and mentor them through the process of VTE prevention performance improvement, tracking results longitudinally. Divya Shroff and her group in Washington, D.C., were enrolled in that VTE prevention collaborative. Their team won an award in VTE prevention by following the road map and by coming up with a good order set for DVT prevention that could be used in their VA hospital and in many other VAs across the country. I think that speaks to the strength of the concepts that we're using."

Each of the award-winning protocols will be presented at an NATF-sponsored program April 9 at Harvard Medical School in Boston. After the presentation, the winning protocols and implementation plans will be available at www.DVTeamCareAward.com to help other hospitals enhance their efforts to prevent DVT.

Three medical centers have been nationally recognized for innovative approaches to preventing DVT and its potentially fatal complications. Central to each of the prevention strategies is a risk assessment tool that is easy to use, built directly into routine care, and linked directly to guideline-recommended choices for prophylaxis.

The North American Thrombosis Forum (NATF), in coordination with the pharmaceutical company Eisai Inc., recognized the following centers with the first DVTeamCare Hospital Award:

• The University of California at San Diego Medical Center was awarded as a representative of medical centers with more than 200 beds. The hospital embedded its VTE prevention protocol into admission, transfer, and perioperative order sets across all medical and surgical services, says Gregory A. Maynard, MD, chief of the division of hospital medicine. The protocol flags three levels of DVT risk, notes possible contraindications for a particular kind of patient, and presents a set of options for guideline-recommended prophylaxis. The protocol can be paper- or computer-based.

 

• The Johns Hopkins Hospital in Baltimore, also awarded as a representative for medical centers with more than 200 beds, developed a mandatory computer-based decision support system to facilitate specialty-specific risk factor assessment and the application of risk-appropriate VTE prophylaxis.

 

• The Washington, D.C., Veterans Affairs Medical Center won in the category representing medical centers with fewer than 200 beds. The hospital designed a seven-step process that walks providers through an evidence-based risk-factor assessment to determine appropriate thromboprophylactic therapy. 

The DVTeamCare Hospital Award reflects NATF's goal of enhancing thrombosis education, prevention, diagnosis, and treatment to improve patient outcomes, says NATF Executive Director Ilene Sussman, PhD.

Dr. Maynard and his UCSD colleagues have made their DVT prophylaxis toolkit available to other hospitalists wanting to lead similar efforts in their own hospital. The toolkit is posted both on the AHRQ and SHM Web sites.

"SHM and AHRQ should feel proud about this because we were one of the first places to do this successfully at such a high level," Dr. Maynard says. "We partnered with others and with SHM to build similar toolkits. SHM built VTE prevention collaboratives that enroll hospitalist leaders and mentor them through the process of VTE prevention performance improvement, tracking results longitudinally. Divya Shroff and her group in Washington, D.C., were enrolled in that VTE prevention collaborative. Their team won an award in VTE prevention by following the road map and by coming up with a good order set for DVT prevention that could be used in their VA hospital and in many other VAs across the country. I think that speaks to the strength of the concepts that we're using."

Each of the award-winning protocols will be presented at an NATF-sponsored program April 9 at Harvard Medical School in Boston. After the presentation, the winning protocols and implementation plans will be available at www.DVTeamCareAward.com to help other hospitals enhance their efforts to prevent DVT.